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Endemic Oral disease > PAP5 - Self performed plaque control 2 > Flashcards

PAP5 - Self performed plaque control 2 Flashcards

1
Q

what year was addition of fluoride to toothpastes?

A

1970

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2
Q

what was the evidence base of De la rosa study?

A

After brushing he found 60% plaque remained. However, regrowth was 27% lower in the group which used toothpaste

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3
Q

what is the role of dentifrice ( dental health providers wishes)?

A

• Anti-caries properties
• Anti-plaque/anti-bacterial
properties
•Desensitising potential •Anti-calculus action
• Abrasive compatible with other dentifrice components.

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4
Q

what do patients want from toothpaste (dentifice)?

A 
• Freshening of breath (anti-
halitosis).
• Stainremoval/whitening 
• Pleasanttaste
• Low cost!
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5
Q

Ideally a toothpaste will do what?

A
  • Suppress the oral flora
  • Inhibit further bacterial colonisation of surfaces
  • Inhibit plaque substrate
  • Dissolution of established colonies
  • Prevent calculus
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6
Q

Name the dentifrice ingredients.

A
  1. Water
  2. Active Components :
    (i) Antibacterial
    (ii) Anti-caries
    (iii) Desensitisers
  3. Abrasives
  4. Detergents and Binding Agents
  5. Thickeners
  6. Humectants and Preservatives
  7. Flavouring & Sweetening Agents
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7
Q

what is the problem with some dentifrice ingredients?

A

some patients allergic to some ingredients and some diseases are worsened by some ingredients

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8
Q

Name 3 abrasives.

A

Calcium carbonate, dicalcium phosphate, aluminium silicate

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9
Q

what are abrasives used to aid?

A

plaque/ stain removal

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10
Q

what should an ideal abrasive do?

A
  1. be relatively inert
  2. have relatively low intrinsic hardness (less than dentine)
  3. Have the appropriate distribution and particle size to provide low abrasiveness to teeth.
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11
Q

what does abrasives need to without causing?

A

Need to clean adequately without causing unacceptable wear of enamel/dentine

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12
Q

what are some abrasives incompatible with?

A

other ingredients eg. Sodium Fluoride and Calcium Carbonate form insoluble Calcium Fluoride

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13
Q

what is abrasives compatible with?

A

monofluorophosphate

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14
Q

why is detergent added to toothpaste?

A
  • foam on use

- Helps distribute the paste around the oral cavity and loosen debris (debris spat out)

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15
Q

Name a detergent and what is the problem?

A

sodium laurel sulphate

-some patients allergic to SLS

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16
Q

why are binding agents such a carboxymethcellulose used in toothpaste?

A

separation of liquid and solid phases of paste during storage

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17
Q

why are thickeners added to toothpaste?

A

give paste consistency (e.g. Silica)

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18
Q

Why are humectants added to toothpaste?

A 
conserve moisture especially if lid
left off (e.g. glycerol)
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19
Q

why are preservatives added to toothpaste?

A

Prevent bacterial growth (eg. Alcohols, Benzoates and Formaldehyde)

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20
Q

what flavours and sweeteners are added to toothpaste?

A

Sorbitol, saccharine, spearmint, peppermint and menthol

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21
Q

why are flavours and sweeteners added?

A

-make the paste palatable

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22
Q

what can some flavouring agents cause?

A

Cause mucosal irritation, ulceration and peri-oral dermatitis

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23
Q

what is the main anti-caries agent?

A

fluoride

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24
Q

what effect does fluoride have on caries?

A

Fluoride pastes have been shown to reduce caries by at least 15-30%

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25
Q

what concentration of fluoride do toothpastes normally have?

A

Pastes usually contain 1000 - 1500ppm fluoride. Must be enough to be
effective but not so high as to cause fluorosis

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26
Q

what is the most common form of fluoride in toothpaste?

A

Sodium Fluoride or Sodium Monofluorophosphate

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27
Q

what various non-fluoride anti-caries agents are used with no evidence base?

A
  • Phosphorus-containing Agents (? raise plaque phosphorus levels)
  • Calcium-containing Agents (? have antacid properties)
  • Antimicrobials and Antibiotics
  • Metal Ions (? Action. Poor taste & toxic in high doses)
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28
Q

why is it difficult to develop an effective anti-bacterial paste?

A

Due to lack of substantivity

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29
Q

what is substantivity?

A

“The potential for a drug (fluoride) to be retained at the required site of action for long enough to be effective) and/or incompatibility with other components”

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30
Q

Describe the active component - Bisbiguanides.

A

Chlorhexidine is a proven anti-septic but its activity is much reduced in pastes. (also staining may occur)

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31
Q

Describe the active component - Phenols.

A

‘Triclosan’ is active against bacteria and yeasts, few side effects, good compatibility and good substantivity. Often combined with co-polymer to increase retention or zinc citrate to increase action.

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32
Q

what are the result of the evidence produced of clinical benefits of using triclosan/copolymer fluoride toothpaste when compared with fluoride toothpaste?

A
  • 22% reduction in plaque
  • 48% reduction in bleeding gums
  • 5% reduction in tooth decay
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33
Q

what enhances the action of triclosan?

A

co-polymer or zinc citrate

34
Q

Name some other active components (Anti-bacterial/Anti-plaque Agents).

A
  • Metal Ions
  • Enzymes
  • Antibiotics
  • Plant Extracts
  • Essential Oils
35
Q

what are the modes of action of anti-bacterialagents( prevention or reduction of)?

A 
Prevention or reduction of:
• Adhesion of plaque pioneer bacterial colonisers on to tooth surface 
• Adhesion of secondary plaque bacteria
• Growth of plaque bacterial species
• Formation of plaque matrix
36
Q

what are the modes of action of anti-bacterial agents( modification of)?

A
  • The inherent plaque biochemistry

* The plaque ecology to induce a less pathogenic flora.

37
Q

what do calculus support the build up of?

A

Calculus has a rough surface which attracts plaque. Plaque accumulation in a susceptible patient will cause disease

38
Q

what are anti-calculus agents known as?

A

‘crystal growth inhibitors’

39
Q

what do anti-calculus agents do?

A
  • Mode of action not well understood but efficacy well documented
  • E.g. Pyrophosphate, Zinc Citrate, Zinc Chloride
40
Q

why do “ecologically sound” paste exists?

A

Due to concerns about fluoride market

41
Q

what substances are contained in herbal or natural toothpastes?

A

plant extracts, seaweed extracts and propolis

42
Q

what are the problems of herbal or natural toothpastes?

A
  1. no fluoride (don’t reduce caries)
  2. very low abrasively (don’t remove plaque)
  3. no evidence base for effectiveness
43
Q

Describe whitening toothpaste.

A

• Marketed for cosmetic properties
• Often contains sodium tripolyphosphate which is
said to loosen the stained matrix on the teeth
• Other agents which are used are enzyme based
• ‘Smoker’s’ toothpastes can be very abrasive.

44
Q

what were the initial concerns of sodium bicarbonate toothpaste were unfounded?

A

high abrasivity

45
Q

what properties of sodium bicarbonate toothpaste have?

A 
Sodium bicarbonate has anti-bacterial activity , inhibits cariogenic bacteria,
Other claimed properties include:
1. acid buffering potential
2. superior stain removal
3. anti-halitosis action
46
Q

what problem is desensitising (active component) trying to prevent?

A

dentine hypersensitivity

47
Q

what are the actions of desensitising agents?

A

block the dentinal tubule, create a layer over the

dentinal surface or reduce sensitivity of the nerve

48
Q

Name some desensitising agents.

A

Potassium Nitrate, Potassium Chloride, NovaminTM, Sodium Fluoride

49
Q

what toothpaste is used for sensitive teeth?

A

Sensodyne (Novamin)

50
Q

what is “NovaMin” trade name for?

A

Calcium sodium phosphosiicate (CSPS) which is a particulate bioactive glass composition

51
Q

what percentage of NovaMin is required in toothpaste to be approved as treatment for dentine hypersensitivity?

A

5% and 7.5% by weight

52
Q

what is NovaMin resistant to?

A

acid

53
Q

Describe the NovaMin action and the outcome.

A
  • Ions released from NovaMin, under a series of chemical reactions, result in the formation of a carbonated hydroxyapatite layer on the dentine surface
  • This new layer is resistant to physical removal (including tooth brushing) and is much harder than the original exposed dentine.
54
Q

What are the overall toothpaste recommendations?

A

i. Use a fluoride toothpaste (High caries risk patients may be prescribed 2800ppm or 5000ppm fluoride)
ii. Brush twice daily
iii. Spit but do not rinse with water or mouthwash after
iv. Consider further agents e.g. desensitising agents / triclosan if beneficial.

55
Q

what do patients like to use and when should this be used?

A
  • Patients like mouthwash
  • Seen as an ‘easy’ alternative to mechanical OHI
  • Apart from VERY specific circumstances it should be considered a cosmetic item
56
Q

what are the potential modes of action of mouthwash?

A
  1. Eliminate all plaque
  2. Reduce plaque levels below disease threshold
  3. Change plaque characteristics so that it is not pathogenic
57
Q

what are the 5 approaches of mouthwashes?

A

i. Antiseptics
ii. Antibiotics
iii. Enzymes to break down plaque structure
iv. Non-enzymes to break down plaque structure
v. Interference with plaque attachment

58
Q

what are the problems with antiseptics?

A

injurious to general health/mucous membranes (alcohol) , had a bad taste or bad smell and that by the time they were diluted enough to be made safe/acceptable, they were no longer effective

59
Q

what are the advantages of antiseptic (mouthwash)?

A

Action is ‘non-specific’
important problems are thus avoided:
1. Development of resistant strains of micro-organisms avoided
2. Development of sensitivity (allergy) of patient to agent
3. Development of superinfections avoided.

60
Q

what are antibacterial agents used to control?

A

supragingival plaque

61
Q

what are the effects of antibacterial agents?

A
  • Antibacterial agents in mouthwashes or toothpastes can only affect supra- gingival plaque
  • They are occasionally used in the control of gingival conditions
  • They will not influence chronic periodontitis
  • They are different to agents directed at subgingival plaque which need to access periodontal pockets in high enough concentrations to produce effects.
62
Q

what is the most common biguanide antiseptic?

A

Chlorhexidine (CHX) gluconate

63
Q

what can all biguanide antiseptics do?

A

All are able to kill a wide variety of organisms by damaging their cell wall

64
Q

what are the effects of chlorhexidine (CHX) Gluconate?

A
  • Effective in vitro against Gram +ve & –ve bacteria including aerobes & anaerobes plus yeasts and fungi
  • Much better at preventing new plaque formation than pre-existing deposits
  • Has much more prolonged anti-plaque properties than other antiseptics ie. ‘substantivity’
  • CHX inhibits some constituents of toothpaste therefore, if used, this should be at a different time to toothbrushing
65
Q

what is the substantivity (persistence of effect of a topically applied drug) of chlorhexidine influenced by?

A

i. Concentration of the drug
ii. Its pH
iii. Its temperature
iv. Length of time of contact of the solution with the oral tissues

66
Q

how is substantivity of chlorhexidine achieved?

A

Property occurs as dicationic CHX molecules are adsorbed onto oral surfaces and then released at bactericidal levels over prolonged periods (can get staining)

67
Q

what CHX concentration usually recommended?

A
  1. 10ml rinse 0.2% solution

2. 15ml rinse of 0.12% solution

68
Q

what are the side effects of chlorhexidine?

A
  • Parotid gland enlargement
  • Increased calculus formation
  • Staining of teeth, mucous membranes and tongue
  • Unpleasant taste / alteration of taste sensation
  • Mucosal redness/burning/erosion
69
Q

What advice is given to patients using chlorhexidine?

A
  • Staining is caused by CHX binding tannins
  • Patients using chlorhexidine gluconate mouthwash should avoid smoking, drinking tea, coffee and red wine during period of use to minimise staining
70
Q

How safe is chlorhexidine?

A

Very safe :
• Poorly absorbed by the GI tract
• displays very low toxicity
• No tetragenic alterations found following long term use
• No reported evidence of carcinogenic substance formation

71
Q

when is chlorhexidine not licensed and dangerous?

A

socket irrigation

72
Q

what are some other mouthwash types?

A

-Oxgenating mouthwashes (hydrogen peroxide )
>inhibit obilgate anaerobes

-Quaternery ammonium compounds
>moderate plaque inhibitory activity

-Phenolic antiseptics
>reduce plaque accumulation but not as good as CHX

-Hexetidine
>anti-inflammatory effect

-Triclosan
>non-ionic antiseptic, moderate plaque inhibitory effects , reduce gingival inflammation

-Delmopinol
> inhibits plaque growth and may reduce gingivitis

-Delmopinol
>same as CHX but doesn’t increase calculus formation

73
Q

what effect do metal ions have?

A
  • Zinc, copper and tin all inhibit plaque
  • Copper & tin cause staining
  • Studies contradictory though zinc is retained by dental plaque and inhibits regrowth
  • Addition of zinc to other antiseptics (eg. Triclosan) seems to have synergistic effect
  • Mechanism unknown
74
Q

Describe the effect of natural mouthwash : sanguinarine.

A
  • Alkaloid derived from blood root plant
  • Contains chemically active ‘iminium’ ion
  • Poorly absorbed from GI tract
  • Retained in plaque for several hours
  • Plaque inhibition - less effective than CHX
  • Not proven in preventing gingivitis
75
Q

what are the disadvantages of alcohol content in mouthwashes?

A
  • Alcohol is drying to the oral mucosa
  • Accidental swallowing by young children may lead to alcohol toxicity (Reported)
  • Alcohol consumption (especially+smoking) increases risk of oral and pharyngeal cancer
  • Frequent use off alcohol containing M/W may increase risk (Weak evidence).
76
Q

what effect can alcohol have on restorations?

A

• May increase the alcohol content of exhaled breath Transient effect
• Can reduce hardness of compositeand hybrid-resin restorations (fail)
Alteration of colour of some restorations also reported.

77
Q

Are mouthwashes recommended?

A

Not generally recommended as part of usual oral hygiene regime however it can be in some situations

78
Q

when are anti-plaque mouthrinses to be used as a replacement for toothbrushing?

A

To replace mechanical cleaning only when this is not possible:
• After oral/periodontal surgery
• After jaw surgery
• Acute oral mucosal/ gingival infections causing pain
• Last resort when patient and carers not able to/willing to brush e.g. special needs patients/nursing homes etc

79
Q

Give a mouthwash summary.

A
  • Mouthwashes NOT recommended for the management of gingivitis or periodontitis
  • They do NOT penetrate the biofilm or get to the depths of pockets
  • Only the bisbiguanides, of which CHX is the most effective
  • This is because they combine substantivity (oral retentiveness) with antibacterial activity
  • Other agents (e.g.CPC, ‘Listerine’, and ‘Triclosan’) have plaque inhibitory effects without substantivity and are not as effective
  • Mouthwashes are very occasionally recommended for specific oral conditions or patient situations.
80
Q

why do anti-plaque mouthwashes have no place as a sole treatment for existing gingivitis or periodontitis?

A
  • they cannot penetrate the biofilm (plaque) or predictably reach the subgingival environment
  • Mouthwashes don’t discriminate and will kill the natural commensals,

Endemic Oral disease (13 decks)

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